Consultant's Corner: Medical Record Keeping

by Christine Hotz, DVM

Medical Record Keeping Requirements

When a complaint involving a veterinarian is filed with the VMB, the subject of the complaint is asked to provide extensive information in his or her defense. One of the most convincing pieces of evidence the veterinarian can present is a thorough medical record. The California Veterinary Medicine Practice Act contains a list of the minimum requirements of a medical record.

(Revised language added July 19, 2004) The California Code of Regulations, Title 16, Section 2032.3 states:

(a) Every veterinarian performing any act requiring a license pursuant to the provisions of Chapter 11, Division 2, of the code, upon any animal or group of animals shall prepare a legible, written or computer generated record concerning the animal or animals which shall contain the following information available:

  1. Name or initials of the veterinarian responsible for entries.
  2. Name, address and phone number of the client.
  3. Name or identity of the animal, herd or flock.
  4. Except for herds or flocks, age, sex, breed, species, and color of the animal.
  5. Dates (beginning and ending) of custody of the animal, if applicable.
  6. A history or pertinent information as it pertains to each animal, herd, or flock's medical status.
  7. Data, including that obtained by instrumentation, from the physical examination.
  8. Treatment and intended treatment plan, including medications, dosages and frequency of use.
  9. Records for surgical procedures shall include a description of the procedure, the name of the surgeon, the type of sedative/anesthetic agents used, their route of administration, and their strength if available in more than one strength.
  10. Diagnosis or tentative diagnosis at the beginning of custody of animal.
  11. If relevant, a prognosis of the animal's condition.
  12. All medications and treatments prescribed and dispensed, including strength, dosage, quantity, and frequency.
  13. Daily progress, if relevant, and disposition of the case.

A veterinarian who complies with the requirements listed above will have at least the basic skeleton of a good medical record. However, if this skeleton is not supplemented with additional remarks and supporting materials, it may not include enough information to support a veterinarian's version of the complaint event. It is much easier to write a complete medical record at the time of examination and treatment, than to try to reconstruct the situation from memory months or years later. Additionally, a narrative written "after the fact" does not carry the same weight of evidence that the medical record does. The VMB has taken the position that "if it's not in the medical records, it didn't happen."

The explosion of technology has expanded the options for treatment and diagnostics available to a veterinarian. If a sophisticated diagnostic workup or treatment is offered, it should be chronicled in the medical record. Likewise, recommendations for a referral to a specialist should also be noted. Documentation of a client's decision NOT to pursue your recommendations is equally important.

A much too common consumer complaint is unauthorized veterinary services. Euthanasias, expensive diagnostics and therapies, and high risk procedures are those that are most likely to be disputed by a client at a later date. It is very difficult for a veterinarian to demonstrate that proper informed consent was obtained if the medical record does not contain a signed consent form. Consents obtained over the phone should be documented in the record, and preferably witnessed and initialed by a staff member. Don't make the mistake of discarding consent forms once it is apparent the animal survived the procedure. Complications and complaints often arise months later.

Phone conversations between veterinarians, technicians, and clients are commonplace in most practice situations. These conversations are just as important as those that occur in the exam room and should be summarized in the medical record. If an animal is co-owned, it may be helpful to note the specific party involved in the conversation, as clients don't always communicate effectively with each other.

Consumers often submit extensive documentation to support their complaint against a veterinarian. It is not unusual for the VMB to receive sworn witness testimony, itemized receipts, before and after photographs, transcripts of phone conversations and office visits, pill vials, foreign objects, and copies of medical records. A veterinarian's records must be clear and complete in order to refute the allegations of a prepared complainant.

Medical Record Keeping Tips

The conscientious veterinarian who wants his or her records to accurately reflect treatments, procedures, and conversations shouldn't need to spend more time on maintaining medical records than caring for patients. The solution is to be as efficient as possible. Below are some suggestions you may find helpful:

  • Use commercial or customized stamps, stick-on exam labels, and preprinted medical record forms to minimize the repetitious part of record keeping.
  • Use customized or standard medical abbreviations. The generous use of abbreviations greatly reduces the volume of material that you must write. Make sure you maintain a list of abbreviations that are used, so that every practice employee can decipher your records.
  • Enlist your staff to help with the record keeping chores. Every staff member should be trained in the art of record keeping. All hospital employees should record their conversations with clients in the medical record. Technicians and assistants can help with documenting treatments and progress notes. Have each individual initial their entries in the record.
  • Preprinted anesthesia forms are an easy way to provide proof of the great job you and your staff do monitoring your anesthetized patients.

The most important reason for excelling at medical record keeping is not to please the VMB or to protect yourself in a lawsuit. The primary purpose of complete medical records is to be able to provide optimum patient care. Very few of us have photographic memories that can remember all the details of a medical case at a later time, without comprehensive written records. Patient care and our professional image suffer if we can't remember what we did or said during the previous office visit. Medical records also provide a convenient way for us to transfer care of a patient to an associate within your own practice or a specialist. After all, another veterinarian will be "holding down the fort" while you're vacationing in Tahiti.